OPT Form 1

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Republic of the Philippines

Department of Agriculture
NATIONAL NUTRITION COUNCIL
OPT Form 1. List Preschoolers Weighed and Nutritional Status
Barangay : _____________________________________ Municipality: ____________ Province: ________________________ Weighing Period: ______________________
Name of Mother/Father

Name of Child

Sex

DOB

Age

Weight

BMI

NS

Prepared by: ____________________________


Print Name & Signature

Submitted to: ____________________________


Print Name & Signature

Date: __________________________________

Date: __________________________________

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